Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brunswick Pointe Transitional Care during CMS and state inspections, most recent first.
Unsanitary food preparation and kitchen equipment conditions were observed in the kitchen. Ice scoops were found on top of the ice machine, the can opener had a buildup of black substance and dirt particles around the blade area, and two employees placed their thumbs in plates of food while preparing trays for service. The dietary cleaning schedule did not include routine cleaning for the can opener.
Infection Control and Hand Hygiene Failures: Staff did not follow contact isolation and glove-use practices for two residents. An LPN entered a resident’s C-diff isolation room without a gown, and CNAs did not clean hands or disinfect a mechanical lift after transfer care. In another instance, a CNA performed incontinence care for a resident and then touched the bed control, basin, and other surfaces with contaminated gloves before removing them and washing hands.
Failure to notify a resident’s representative of a hospital transfer. A resident with respiratory failure, ALS, COPD, trach status, edema, and pneumonia was sent to the ER via 911, but the nurse did not successfully notify the daughter and did not leave a message after unsuccessful calls. The daughter later learned of the transfer from the hospital, and staff confirmed there was no POA on file and that the daughter was the person to notify.
Care plans were not revised for two residents with significant medical needs. One resident had a PICC line with orders for routine saline flushes, but no IV therapy or maintenance care plan was in place. Another resident with ALS, respiratory failure, and a Foley catheter had catheter care orders, but the care plan was not updated to reflect the catheter until later chart audits. The DON confirmed the missing and delayed care plan updates.
Mechanical lift transfers were not comprehensively assessed or clearly care planned for three residents reviewed for accidents. For residents with diagnoses including fractures, Parkinson’s disease, CHF, and other chronic conditions, the TARs, care plans, and Kardexes identified use of a mechanical lift but did not specify whether one or two staff were required. Transfer tasks documented two-person assistance, while resident interviews and staff statements indicated one person was sometimes used. Interviews with nursing leadership confirmed the facility did not complete resident assessments for mechanical lift transfer safety or the number of staff needed.
Two residents had deficiencies related to catheter care and UTI follow-up. One resident’s urine culture grew Klebsiella pneumoniae, but the physician was not notified when final results were available and the ordered antibiotic was delayed because the medication supply was incomplete. Another resident with an indwelling catheter had no documentation that the drainage bag was secured, and staff observed the bag dangling and later lying on the floor; an RN and LPN confirmed the bag was not secured.
A resident with CHF, chronic respiratory failure, COPD, AFib, diabetes, and hospice care was ordered oxygen at 1 to 5 LPM by NC to keep O2 saturation at 90%. The MAR documented oxygen at 6 LPM on multiple shifts without any record of a physician or hospice order change, and staff confirmed oxygen settings were to remain within ordered parameters.
Medication Error Rate Exceeded 5% During Insulin Pen Administration. A resident with DM, HF, dementia, anxiety, chronic respiratory failure, and schizophrenia was observed receiving insulin. An RN dialed both Lantus and Humalog pens to the ordered doses before priming them, then primed each pen after dialing; the RN confirmed she did not know to prime the pens upright before selecting the dose. The facility’s medication error rate was calculated at 7.14%, and the policy on safe injection practices did not address insulin pen administration.
A deficiency was identified when the facility failed to provide adequate weekend staffing, as shown by staffing data indicating excessively low coverage. Leadership confirmed that increased resident acuity, especially in the vent unit, contributed to the staffing shortfall, affecting all residents in the facility.
A resident was discharged without receiving all prescribed medications, specifically Mounjaro 7.5 mg injections for diabetes. The nurse responsible did not check for remaining doses, assuming the resident would refill the prescription after discharge. This led to a delay in medication administration, as the pharmacy could not refill it until after the scheduled date.
A resident suffered a fracture to her left upper arm when her wheelchair was not properly secured during transportation in the facility van, causing it to tip over. The resident, who had a history of diabetes, end-stage renal disease, and dementia, reported increased shoulder pain upon returning from dialysis. An X-ray confirmed the fracture, and the facility's investigation revealed a loose wheelchair anchor strap as the cause. The transport aide admitted to not securing the wheelchair tightly enough, leading to the incident.
Unsanitary Food Preparation and Kitchen Equipment Conditions
Penalty
Summary
The facility failed to prepare and distribute food and ice under sanitary conditions. During observation of the kitchen, two small ice scoops and one large ice scoop were found laying on top of the ice machine, and a container on the wall to the right of the ice machine was used for placing the large ice scoop when not in use. The can opener also had a buildup of a black substance with dirt particles on and around the blade area. During meal preparation and tray assembly, Employee #358 placed her thumb in a plate of food while preparing it for service, and Employee #340 also placed their thumb in a plate of food while plates were being prepared for distribution to residents. Corporate Chef #341 confirmed the thumb contact with the food and immediately approached both employees and asked them to put on a glove to plate the dishes. Review of the dietary cleaning schedule for April 2026 revealed no sections for routine cleaning of the can opener.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure infection control practices were followed for isolation precautions and proper glove use for two residents. Resident #16 had diagnoses including metabolic encephalopathy, C-diff, COPD, malnutrition, anxiety, and depression, and the MDS showed impaired cognition and dependence with transfers. The physician ordered contact isolation for C-diff, and the care plan stated staff and visitors were to don a gown and gloves before entering the room. During observation of Resident #16’s room, an LPN was administering medications while wearing gloves but not a gown, then removed the gloves at the doorway, exited the room, and sanitized her hands. The LPN stated she only needed gloves and not a gown to administer medications, and said gowns were only needed if providing direct care. In a later observation, two CNAs entered the resident’s room with a mechanical lift for a transfer while wearing gowns and gloves; after the transfer, one CNA removed her gown and gloves and left the room without washing her hands or wiping down the mechanical lift, and the other CNA removed her gown and gloves and sanitized her hands. Both CNAs stated they had not been trained to wipe down the mechanical lift after use in an isolation room. For Resident #69, the MDS showed the resident was cognitively intact, required maximal assistance for toileting hygiene, and was frequently incontinent of bowel and bladder. During observed incontinence care, a CNA completed care and then, while still wearing contaminated gloves, touched the bed control, handled the basin used during the procedure, dumped water into the toilet, touched the paper towel dispenser, and wiped out the basin before removing gloves and washing hands. The CNA verified the observation. The facility policy stated hand hygiene was to be performed before and after resident contact, after contact with bodily fluids or contaminated surfaces, and after contact with objects and surfaces in the resident’s environment.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure Resident #3’s representative was notified when the resident was transferred to the hospital. Resident #3 was admitted with diagnoses including acute and chronic respiratory failure, ALS, edema, COPD, tracheostomy status, and pneumonia. The MDS assessment dated 02/127/26 indicated the resident had memory problems and was dependent on activities of daily living. The profile page identified the resident as her own representative and listed Emergency Contact #1 with a phone number and email address, and Emergency Contact #2 with a phone number. Progress notes dated 04/23/26 documented that Resident #3 was sent via 911 to the ER and that the nurse attempted to call the daughter and would continue trying to contact her, but the note did not state whether a message was left. During interview, Emergency Contact #1 stated she was upset because she was not notified and learned the resident was in the ER from the hospital. RN #225 stated she called Emergency Contact #1 twice, was unsuccessful, and did not leave a message after either call. SSD #249 stated there was no POA on file and that Emergency Contact #1 would be the person to notify. The facility policy titled Change of Condition stated the charge nurse will notify the resident, physician, and guardian/interested family member of an emergent unstable condition or disease.
Care plans were not updated for IV therapy and indwelling catheter care
Penalty
Summary
Failure to develop, review, and revise complete care plans within 7 days of the comprehensive assessment was identified for two residents. Resident #21 was admitted with chronic respiratory failure, heart failure, depression, irritable bowel syndrome, neuromuscular dysfunction of the bladder, acute kidney disease, and anxiety. The quarterly MDS showed cognition was intact and the resident was dependent for activities of daily living. The April 2026 MAR included orders to flush a PICC line with 10 mL normal saline after medication administration and before medication administration every shift, but the care plan did not include IV therapy or maintenance. The DON verified during interview that there was no IV or maintenance care plan for this resident. Resident #3 was admitted with acute and chronic respiratory failure, ALS, edema, COPD, tracheostomy status, and pneumonia. The comprehensive MDS showed the resident was understood and had memory problems, was dependent for activities of daily living, and was incontinent of bowel and bladder. April 2026 physician orders included catheter care every shift, changing the indwelling catheter for signs of infection as needed, and monitoring the Foley stabilization device daily. Observation showed the resident in bed on a ventilator with tube feeding running and a Foley catheter draining. The care plan dated 02/20/26 addressed bowel incontinence and an indwelling catheter related to wound and diuretic use, but it was not updated to reflect the catheter until 04/28/26; the DON confirmed the catheter care plan was updated during chart audits on 04/28/26.
Mechanical Lift Transfers Lacked Resident-Specific Assistance Assessments
Penalty
Summary
The facility failed to ensure residents were comprehensively assessed to determine the level of staff assistance required for mechanical lift transfers and failed to ensure care plans were in place to specify the appropriate level of assistance. This involved three residents reviewed for accidents: Resident #20, Resident #61, and Resident #79. The report also identified 34 additional residents who required a mechanical lift for transfers, and the census was 78. Resident #20 was admitted with diagnoses including a nondisplaced comminuted fracture of the left patella, osteoarthritis, COPD, and restless legs syndrome, and was cognitively intact. Her orders, TAR, care plan, and Kardex all indicated use of a mechanical lift for transfers, but none specified whether one or two people were required. The transfer task documented that she was totally dependent for transfers and noted two-person assistance with a mechanical lift. During interview, Resident #20 stated the facility sometimes used one person for mechanical lift transfers because it was sometimes hard to find someone. Resident #61 was cognitively intact and had diagnoses including fusion of spine, hemangioma of intra-abdominal structures, CHF, need for assistance with personal care, and Parkinson’s disease. His TAR and Kardex indicated use of a mechanical lift, but neither specified whether one or two people were required, while the transfer task documented two-person assistance. Resident #61 stated the facility only had one person to help with mechanical lift transfers at times and believed this was due to staffing. Resident #79 was cognitively intact and dependent on staff for transfers; her TAR and Kardex indicated use of a mechanical lift, but did not specify the number of staff needed, while the transfer task noted two staff members when the lift was used. Resident #79 stated the facility just had one person assisting her when using the mechanical lift. Interviews with nursing staff and administration confirmed that the facility did not complete resident assessments for transfer safety related to mechanical lifts and the number of staff assistance required, and that care plans and Kardex entries did not specify how many staff were required.
Catheter Care and UTI Follow-Up Deficiencies
Penalty
Summary
Proper infection control measures were not implemented for care and treatment of a resident’s urinary catheter, and a urinary tract infection was not addressed timely for another resident. One resident was admitted with diagnoses including constipation, stress incontinence, type 2 diabetes, heart failure, dementia, anxiety, chronic respiratory failure, and schizophrenia. A straight catheter specimen was obtained using sterile technique, and the urine culture later identified Klebsiella pneumoniae. The final lab results were approved, but there was no evidence the physician was notified that day. The NP was not notified until the next day, when an antibiotic order for levofloxacin was given. The facility’s automatic medication delivery system had only one 250 mg levofloxacin available, and the first dose of the ordered 750 mg antibiotic was not administered until the following day. A second resident with heart disease, kidney disease, COPD, prostate cancer, obstructive and reflux uropathy, and urinary retention had an indwelling urinary catheter and was dependent for toileting hygiene and required moderate assistance for personal hygiene. The care plan directed catheter care and monitoring for signs and symptoms of UTI. However, nursing documentation from the review period did not show whether the resident was manipulating the drainage bag or whether the bag was secured to the bed. During observation, the resident was seen raising the bed with the catheter drainage bag dangling in the air, not secured to the bed, and later the drainage bag was observed lying on the floor. Staff confirmed the bag was not secured and on the floor.
Oxygen Administered Outside Physician Order
Penalty
Summary
Failure to provide oxygen per physician order occurred for Resident #93, who was admitted with diagnoses including heart failure, chronic respiratory failure, COPD, atrial fibrillation, and diabetes. The care plan identified respiratory deficiencies and the need to administer oxygen as ordered, and the physician order dated 12/26/25 directed oxygen at 1 to 5 liters per minute by nasal cannula to maintain oxygen saturation of 90% every shift for COPD. The resident’s significant change MDS indicated moderate cognitive impairment, use of supplemental oxygen, and hospice care. Review of the medical record from 02/28/26 through 03/14/26 showed no documentation that the physician or hospice providers changed the oxygen order. The MAR documented oxygen at 6 liters per minute on multiple shifts, including 03/03/26, 03/04/26, 03/07/26, 03/08/26, 03/10/26, 03/11/26, and 03/12/26, which was outside the ordered range. A regional nurse verified the findings, and an LPN stated oxygen settings were to be checked for the correct setting and staff were not to increase oxygen outside of order parameters; if the resident could not maintain oxygen saturation above 90% with the current order, the provider was to be notified. The facility policy stated oxygen was to be administered by physician order and the physician notified as needed for changes with oxygen use.
Medication Error Rate Exceeded 5% During Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with the error rate calculated at 7.14% based on two medication errors out of 28 medication administration opportunities. The deficiency affected one resident who was observed during medication administration and whose record showed diagnoses including constipation, stress incontinence, type 2 diabetes, heart failure, dementia, anxiety, chronic respiratory failure, and schizophrenia. The resident’s MDS assessment dated 04/13/26 indicated cognition was intact, the resident was dependent in activities of daily living, and received insulin. During observation of medication administration, an RN obtained the resident’s blood sugar of 228 and prepared both Lantus and Humalog insulin pens. The RN dialed each pen to the ordered dose before entering the room, then stated she was going to prime the pen and proceeded to prime the Lantus pen after it had already been dialed to 80 units, and later primed the Humalog pen after it had already been dialed to 4 units. In interview, the RN verified she dialed the dose and then primed the pens and stated she did not know to hold the insulin pen upright while priming before dialing the dose. Manufacturer instructions for both insulin pens stated the pen should be primed before each injection, and the facility policy titled Safe Injection Practices did not address procedures to administer insulin by pen.
Deficiency Due to Inadequate Weekend Staffing
Penalty
Summary
The facility failed to ensure adequate weekend staffing, as evidenced by the Staffing Data Report for the fourth quarter, which indicated excessively low weekend staffing levels. This deficiency had the potential to affect all 89 residents in the facility. The issue was confirmed through interviews with the Administrator and the Regional Human Resources Director, who both acknowledged that the facility had reported accurate staffing hours but still triggered for low weekend staffing due to increased resident acuity, particularly in the vent unit. The deficiency was identified through review of staffing records and was corroborated by facility leadership, who noted that the increase in resident acuity contributed to the staffing shortfall. The report does not mention any specific residents or individual incidents but establishes that the staffing levels were insufficient to meet the needs of the entire resident population during weekends for the period in question.
Failure to Provide Medication at Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, leading to a deficiency in discharge planning. The resident, who had intact cognition and was diagnosed with type two diabetes, chronic osteomyelitis, and chronic kidney disease, was discharged without receiving all prescribed medications. Specifically, the resident did not receive the Mounjaro 7.5 mg injections for diabetes management upon discharge, despite having a physician's order for the medication. The discharge summary indicated that all medications were sent with the resident, but the Discharge Medication Receipt confirmed the omission of Mounjaro. The issue arose because the nurse responsible for the discharge did not check the refrigerator for the remaining Mounjaro injections, assuming the resident would refill the prescription post-discharge. Consequently, the resident experienced a delay in receiving the medication, as the pharmacy could not refill it until after the scheduled date. The facility's policy required all medications, except controlled substances, to be provided at discharge, but this was not adhered to, resulting in the destruction of the unused Mounjaro after the resident's departure.
Failure to Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safe transportation of residents in the facility van, resulting in actual harm to a resident. On 07/15/24, a resident's wheelchair was not properly secured during transportation, causing it to tip over. The resident's weight rested on the left seatbelt shoulder strap, leading to a fracture in her left upper arm. This incident affected one of the three residents reviewed for transportation safety. The resident involved had a medical history that included diabetes, end-stage renal disease, and unspecified dementia, and was moderately cognitively impaired. Upon returning from dialysis, the resident reported increased left shoulder pain, and an X-ray confirmed a fracture. Interviews with the resident and staff revealed that the wheelchair was not securely fastened, and the resident's wheelchair tilted during a sharp turn into the facility parking lot. The facility's investigation confirmed that one of the wheelchair anchor straps was loose, allowing the wheelchair to tilt. The facility's policy required that wheelchairs be secured with at least four lockdown straps, allowing no more than a quarter inch of wheel movement. However, the transport aide admitted to not securing the wheelchair tightly enough, which led to the incident. The resident was subsequently sent to the hospital for further evaluation, where a CT scan showed no head injury, but the resident was treated for a urinary tract infection and returned to the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brunswick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearlview Rehab & Wellness Ctr | 1.5 mi | ★★★★★ | 0 | 0 |
| Willowood Care Center Of Brunswick | 1.5 mi | ★★★★★ | 2 | 0 |
| Strongsville Healthcare And Rehabilitation | 3.8 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Medina | 4.5 mi | ★★★★★ | 1 | 0 |
| Altenheim | 5.4 mi | ★★★★★ | 4 | 0 |
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